No. 79. An act relating to health insurance, Medicaid, the Vermont Health Benefit Exchange, and the Green Mountain Care Board. (H.107) It is hereby enacted by the General Assembly of the State of Vermont: Health Insurance Sec. 1. 8 V.S.A. 4079 is amended to read: 4079. GROUP INSURANCE POLICIES; DEFINITIONS Group health insurance is hereby declared to be that form of health insurance covering one or more persons, with or without their dependents, and issued upon the following basis: (1)(A) Under a policy issued to an employer, who shall be deemed the policyholder, insuring at least one employee of such employer, for the benefit of persons other than the employer. The term employees, as used herein, shall be deemed to include the officers, managers, and employees of the employer, the partners, if the employer is a partnership, the officers, managers, and employees of subsidiary or affiliated corporations of a corporation employer, and the individual proprietors, partners, and employees of individuals and firms, the business of which is controlled by the insured employer through stock ownership, contract, or otherwise. The term employer, as used herein, may be deemed to include any municipal or governmental corporation, unit, agency, or department thereof and the proper officers as such, of any unincorporated municipality or department thereof, as well as private individuals, partnerships, and corporations.
No. 79 Page 2 of 93 (B) In accordance with section 3368 of this title, an employer domiciled in another jurisdiction that has more than 25 certificate-holder employees whose principal worksite and domicile is in Vermont and that is defined as a large group in its own jurisdiction and under the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 1304, as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, may purchase insurance in the large group health insurance market for its Vermont-domiciled certificate-holder employees. Sec. 2. 8 V.S.A. 4089a is amended to read: 4089a. MENTAL HEALTH CARE SERVICES REVIEW (b) Definitions. As used in this section: (4) Review agent means a person or entity performing service review activities within one year of the date of a fully compliant application for licensure who is either affiliated with, under contract with, or acting on behalf of a business entity in this state; or a third party State and who provides or administers mental health care benefits to citizens of Vermont members of health benefit plans subject to the Department s jurisdiction, including a health insurer, nonprofit health service plan, health insurance service organization, health maintenance organization or preferred provider organization, including
No. 79 Page 3 of 93 organizations that rely upon primary care physicians to coordinate delivery of services, authorized to offer health insurance policies or contracts in Vermont. (g) Members of the independent panel of mental health care providers shall be compensated as provided in 32 V.S.A. 1010(b) and (c). [Deleted.] Sec. 3. 8 V.S.A. 4089i is amended to read: 4089i. PRESCRIPTION DRUG COVERAGE (d) For prescription drug benefits offered in conjunction with a high-deductible health plan (HDHP), the plan may not provide prescription drug benefits until the expenditures applicable to the deductible under the HDHP have met the amount of the minimum annual deductibles in effect for self-only and family coverage under Section 223(c)(2)(A)(i) of the Internal Revenue Code of 1986 for self-only and family coverage, respectively, except that a plan may offer first-dollar prescription drug benefits to the extent permitted under federal law. Once the foregoing expenditure amount has been met under the HDHP, coverage for prescription drug benefits shall begin, and the limit on out-of-pocket expenditures for prescription drug benefits shall be as specified in subsection (c) of this section. (e)(1) A health insurance or other health benefit plan offered by a health insurer or by a pharmacy benefit manager on behalf of a health insurer that
No. 79 Page 4 of 93 provides coverage for prescription drugs and uses step-therapy protocols shall not require failure on the same medication on more than one occasion for continuously enrolled members or subscribers. (2) Nothing in this subsection shall be construed to prohibit the use of tiered co-payments for members or subscribers not subject to a step-therapy protocol. (f)(1) A health insurance or other health benefit plan offered by a health insurer or by a pharmacy benefit manager on behalf of a health insurer that provides coverage for prescription drugs shall not require, as a condition of coverage, use of drugs not indicated by the federal Food and Drug Administration for the condition diagnosed and being treated under supervision of a health care professional. (2) Nothing in this subsection shall be construed to prevent a health care professional from prescribing a medication for off-label use. (g) As used in this section: (1) Health care professional means an individual licensed to practice medicine under 26 V.S.A. chapter 23 or 33, an individual certified as a physician assistant under 26 V.S.A. chapter 31, or an individual licensed as an advanced practice registered nurse under 26 V.S.A. chapter 28. (2) Health insurer shall have the same meaning as in 18 V.S.A. 9402.
No. 79 Page 5 of 93 (2)(3) Out-of-pocket expenditure means a co-payment, coinsurance, deductible, or other cost-sharing mechanism. (3)(4) Pharmacy benefit manager shall have the same meaning as in section 4089j of this title. (5) Step therapy means protocols that establish the specific sequence in which prescription drugs for a specific medical condition are to be prescribed. (f)(h) The department of financial regulation Department of Financial Regulation shall enforce this section and may adopt rules as necessary to carry out the purposes of this section. Sec. 4. 8 V.S.A. 4092(b) is amended to read: (b) Coverage for a newly born child shall be provided without notice or additional premium for no less than 31 60 days after the date of birth. If payment of a specific premium or subscription fee is required in order to have the coverage continue beyond such 31-day 60-day period, the policy may require that notification of birth of newly born child and payment of the required premium or fees be furnished to the insurer or nonprofit service or indemnity corporation within a period of not less than 31 60 days after the date of birth. Sec. 5. 18 V.S.A. 9418 is amended to read: 9418. PAYMENT FOR HEALTH CARE SERVICES (a) Except as otherwise specified, as used in this subchapter:
No. 79 Page 6 of 93 (17) Product means, to the extent permitted by state and federal law, one of the following types of categories of coverage for which a participating provider may be obligated to provide health care services pursuant to a health care contract: (A) Health health maintenance organization; (B) Preferred preferred provider organization; (C) Fee-for-service fee-for-service or indemnity plan; (D) Medicare Advantage HMO plan; (E) Medicare Advantage private fee-for-service plan; (F) Medicare Advantage special needs plan; (G) Medicare Advantage PPO; (H) Medicare supplement plan; (I) Workers workers compensation plan; or (J) Catamount Health; or (K) Any any other commercial health coverage plan or product. (b) No later than 30 days following receipt of a claim, a health plan, contracting entity, or payer shall do one of the following: (1) Pay or reimburse the claim. (2) Notify the claimant in writing that the claim is contested or denied. The notice shall include specific reasons supporting the contest or denial and a
No. 79 Page 7 of 93 description of any additional information required for the health plan, contracting entity, or payer to determine liability for the claim. (3) Pend a claim for services rendered to an enrollee during the second and third months of the consecutive three-month grace period required for recipients of advance payments of premium tax credits pursuant to 26 U.S.C. 36B. In the event the enrollee pays all outstanding premiums prior to the exhaustion of the grace period, the health plan, contracting entity, or payer shall have 30 days following receipt of the outstanding premiums to proceed as provided in subdivision (1) or (2) of this subsection, as applicable. Sec. 5a. 18 V.S.A. 9418b(g)(4) is amended to read: (4) A health plan shall respond to a completed prior authorization request from a prescribing health care provider within 48 hours for urgent requests and within 120 hours two business days of receipt for non-urgent requests. The health plan shall notify a health care provider of or make available to a health care provider a receipt of the request for prior authorization and any needed missing information within 24 hours of receipt. If a health plan does not, within the time limits set forth in this section, respond to a completed prior authorization request, acknowledge receipt of the request for prior authorization, or request missing information, the prior authorization request shall be deemed to have been granted.
No. 79 Page 8 of 93 Standardized Claims and Edits Sec. 5b. STANDARDIZED HEALTH INSURANCE CLAIMS AND EDITS (a)(1) As part of moving away from fee-for-service and toward other models of payment for health care services in Vermont, the Green Mountain Care Board, in consultation with the Department of Vermont Health Access, health care providers, health insurers, and other interested stakeholders, shall develop a complete set of standardized edits and payment rules based on Medicare or on another set of standardized edits and payment rules appropriate for use in Vermont. The Board and the Department shall adopt by rule the standards and payment rules that health care providers, health insurers, and other payers shall use beginning on January 1, 2015 and that Medicaid shall use beginning on January 1, 2017. (2) The Green Mountain Care Board and the Department of Vermont Health Access shall report to the General Assembly on or before February 15, 2014 on the progress toward a complete set of standardized edits and payment rules. (b) The Department of Vermont Health Access s request for proposals for the Medicaid Management Information System (MMIS) claims payment system shall ensure that the MMIS will: (1) have the capability to include uniform edit standards and payment rules developed pursuant to this section; and
No. 79 Page 9 of 93 (2) include full transparency of edit standards, payment rules, prior authorization guidelines, and other utilization review provisions, including the source or basis in evidence for the standards and guidelines. (c)(1) The Department of Vermont Health Access shall ensure that contracts for benefit management and claims management systems in effect on January 1, 2017 include full transparency of edit standards, payment rules, prior authorization guidelines, and other utilization review provisions, including the source or basis in evidence for the standards and guidelines. (2) The Department of Financial Regulation shall ensure that beginning on January 1, 2015, health insurers and their subcontractors for benefit management and claim management systems include full transparency of edit standards, payment rules, prior authorization guidelines, and other utilization review provisions, including the source or basis in evidence for the standards and guidelines. In addition to any other remedy available to the Commissioner under Title 8 or Title 18, a health insurer, subcontractor, or other person who violates the requirements of this section may be assessed an administrative penalty of not more than $2,000.00 for each day of noncompliance. (d) As used in this section: (1) Health care provider means a person, partnership, corporation, facility, or institution licensed or certified or authorized by law to administer health care in this State.
No. 79 Page 10 of 93 (2) Health insurer means a health insurance company, a nonprofit hospital or medical service corporation, a managed care organization, and, to the extent permitted under federal law, any administrator of an insured, self-insured, or publicly funded health care benefit plan offered by a public or private entity. Health Insurance Rate Review Sec. 5c. 8 V.S.A. 4062 is amended to read: 4062. FILING AND APPROVAL OF POLICY FORMS AND PREMIUMS (a)(1) No policy of health insurance or certificate under a policy filed by an insurer offering health insurance as defined in subdivision 3301(a)(2) of this title, a nonprofit hospital or medical service corporation, health maintenance organization, or a managed care organization and not exempted by subdivision 3368(a)(4) of this title shall be delivered or issued for delivery in this state State, nor shall any endorsement, rider, or application which becomes a part of any such policy be used, until: (A) a copy of the form, and of the rules for the classification of risks has been filed with the Department of Financial Regulation and a copy of the premium rates, and rules for the classification of risks pertaining thereto have has been filed with the commissioner of financial regulation Green Mountain Care Board; and (B) a decision by the Green Mountain Care board Board has been applied by the commissioner as provided in subdivision (2) of this subsection issued a decision approving, modifying, or disapproving the proposed rate.
No. 79 Page 11 of 93 (2)(A) Prior to approving a rate pursuant to this subsection, the commissioner shall seek approval for such rate from the Green Mountain Care board established in 18 V.S.A. chapter 220. The commissioner shall make a recommendation to the Green Mountain Care board about whether to approve, modify, or disapprove the rate within 30 days of receipt of a completed application from an insurer. In the event that the commissioner does not make a recommendation to the board within the 30-day period, the commissioner shall be deemed to have recommended approval of the rate, and the Green Mountain Care board shall review the rate request pursuant to subdivision (B) of this subdivision (2). (B) The Green Mountain Care board Board shall review rate requests forwarded by the commissioner pursuant to subdivision (A) of this subdivision (2) and shall approve, modify, or disapprove a rate request within 30 90 calendar days of receipt of the commissioner s recommendation or, in the absence of a recommendation from the commissioner, the expiration of the 30-day period following the department s receipt of the completed application. In the event that the board does not approve or disapprove a rate within 30 days, the board shall be deemed to have approved the rate request after receipt of an initial rate filing from an insurer. If an insurer fails to provide necessary materials or other information to the Board in a timely manner, the Board may extend its review for a reasonable additional period of time, not to exceed 30 calendar days.
No. 79 Page 12 of 93 (C) The commissioner shall apply the decision of the Green Mountain Care board as to rates referred to the board within five business days of the board s decision. (B) Prior to the Board s decision on a rate request, the Department of Financial Regulation shall provide the Board with an analysis and opinion on the impact of the proposed rate on the insurer s solvency and reserves. (3) The commissioner Board shall review policies and rates to determine whether a policy or rate is affordable, promotes quality care, promotes access to health care, protects insurer solvency, and is not unjust, unfair, inequitable, misleading, or contrary to the laws of this state State. The commissioner shall notify in writing the insurer which has filed any such form, premium rate, or rule if it contains any provision which does not meet the standards expressed in this section. In such notice, the commissioner shall state that a hearing will be granted within 20 days upon written request of the insurer. In making this determination, the Board shall consider the analysis and opinion provided by the Department of Financial Regulation pursuant to subdivision (2)(B) of this subsection. (b) The commissioner may, after a hearing of which at least 20 days written notice has been given to the insurer using such form, premium rate, or rule, withdraw approval on any of the grounds stated in this section. For premium rates, such withdrawal may occur at any time after applying the decision of the Green Mountain Care board pursuant to subdivision (a)(2)(c)
No. 79 Page 13 of 93 of this section. Disapproval pursuant to this subsection shall be effected by written order of the commissioner which shall state the ground for disapproval and the date, not less than 30 days after such hearing when the withdrawal of approval shall become effective. (c) In conjunction with a rate filing required by subsection (a) of this section, an insurer shall file a plain language summary of any requested rate increase of five percent or greater. If, during the plan year, the insurer files for rate increases that are cumulatively five percent or greater, the insurer shall file a summary applicable to the cumulative rate increase the proposed rate. All summaries shall include a brief justification of any rate increase requested, the information that the Secretary of the U.S. Department of Health and Human Services (HHS) requires for rate increases over 10 percent, and any other information required by the commissioner Board. The plain language summary shall be in the format required by the Secretary of HHS pursuant to the Patient Protection and Affordable Care Act of 2010, Public Law 111-148, as amended by the Health Care and Education Reconciliation Act of 2010, Public Law 111-152, and shall include notification of the public comment period established in subsection (d)(c) of this section. In addition, the insurer shall post the summaries on its website. (d)(c)(1) The commissioner Board shall provide information to the public on the department s Board s website about the public availability of the filings and summaries required under this section.
No. 79 Page 14 of 93 (2)(A) Beginning no later than January 1, 2012 2014, the commissioner Board shall post the rate filings pursuant to subsection (a) of this section and summaries pursuant to subsection (c)(b) of this section on the department s Board s website within five calendar days of filing. The Board shall also establish a mechanism by which members of the public may request to be notified automatically each time a proposed rate is filed with the Board. (B) The department Board shall provide an electronic mechanism for the public to comment on proposed rate increases over five percent all rate filings. The public shall have 21 days from the posting of the summaries and filings to provide Board shall accept public comment on each rate filing from the date on which the Board posts the rate filing on its website pursuant to subdivision (A) of this subdivision (2) until 15 calendar days after the Board posts on its website the analyses and opinions of the Department of Financial Regulation and of the Board s consulting actuary, if any, as required by subsection (d) of this section. The department Board shall review and consider the public comments prior to submitting the policy or rate for the Green Mountain Care board s approval pursuant to subsection (a) of this section. The department shall provide the Green Mountain Care board with the public comments for its consideration in approving any rates issuing its decision. (3)(A) In addition to the public comment provisions set forth in this subsection, the Office of the Health Care Advocate established in 18 V.S.A. chapter 229, acting on behalf of health insurance consumers in this State, may,
No. 79 Page 15 of 93 within 30 calendar days after the Board receives an insurer s rate request pursuant to this section, submit to the Board, in writing, suggested questions regarding the filing for the Board to provide to its contracting actuary, if any. (B) The Office of the Health Care Advocate may also submit to the Board written comments on an insurer s rate request. The Board shall post the comments on its website and shall consider the comments prior to issuing its decision. (e)(d)(1) No later than 60 calendar days after receiving an insurer s rate request pursuant to this section, the Green Mountain Care Board shall make available to the public the insurer s rate filing, the Department s analysis and opinion of the effect of the proposed rate on the insurer s solvency, and the analysis and opinion of the rate filing by the Board s contracting actuary, if any. (2) The Board shall post on its website, after redacting any confidential or proprietary information relating to the insurer or to the insurer s rate filing: (A) all questions the Board poses to its contracting actuary, if any, and the actuary s responses to the Board s questions; and (B) all questions the Board, the Board s contracting actuary, if any, or the Department poses to the insurer and the insurer s responses to those questions.
No. 79 Page 16 of 93 (e) Within 30 calendar days after making the rate filing and analysis available to the public pursuant to subsection (d) of this section, the Board shall: (1) conduct a public hearing, at which the Board shall: (A) call as witnesses the Commissioner of Financial Regulation or designee and the Board s contracting actuary, if any, unless all parties agree to waive such testimony; and (B) provide an opportunity for testimony from the insurer; the Office of the Health Care Advocate; and members of the public; (2) at a public hearing, announce the Board s decision of whether to approve, modify, or disapprove the proposed rate; and (3) issue its decision in writing. (f)(1) The insurer shall notify its policyholders of the Board s decision in a timely manner, as defined by the Board by rule. (2) Rates shall take effect on the date specified in the insurer s rate filing. (3) If the Board has not issued its decision by the effective date specified in the insurer s rate filing, the insurer shall notify its policyholders of its pending rate request and of the effective date proposed by the insurer in its rate filing. (g) An insurer, the Office of the Health Care Advocate, and any member of the public with party status, as defined by the Board by rule, may appeal a
No. 79 Page 17 of 93 decision of the Board approving, modifying, or disapproving the insurer s proposed rate to the Vermont Supreme Court. (h)(1) The following provisions of this This section shall apply only to policies for major medical insurance coverage and shall not apply to policies for specific disease, accident, injury, hospital indemnity, dental care, vision care, disability income, long-term care, or other limited benefit coverage:; to Medicare supplemental insurance; or (A) the requirement in subdivisions (a)(1) and (2) of this section for the Green Mountain Care board s approval on rate requests; (B) the review standards in subdivision (a)(3) of this section as to whether a policy or rate is affordable, promotes quality care, and promotes access to health care; and (C) subsections (c) and (d) of this section. (2) The exemptions from the provisions described in subdivisions (1)(A) through (C) of this subsection shall also apply to benefit plans that are paid directly to an individual insured or to his or her assigns and for which the amount of the benefit is not based on potential medical costs or actual costs incurred. (3) Medicare supplemental insurance policies shall be exempt only from the requirement in subdivisions (a)(1) and (2) of this section for the Green Mountain Care board s approval on rate requests and shall be subject to the remaining provisions of this section.
No. 79 Page 18 of 93 (i) Notwithstanding the procedures and timelines set forth in subsections (a) through (e) of this section, the Board may establish, by rule, a streamlined rate review process for certain rate decisions, including proposed rates affecting fewer than a minimum number of covered lives and proposed rates for which a de minimis increase, as defined by the Board by rule, is sought. Sec. 5d. 8 V.S.A. 4062a is amended to read: 4062a. FILING FEES Each filing of a policy, contract, or document form or premium rates or rules, submitted pursuant to section 4062 of this title, shall be accompanied by payment to the commissioner Commissioner or the Green Mountain Care Board, as appropriate, of a nonrefundable fee of $50.00 $150.00. Sec. 5e. 8 V.S.A. 4089b(d)(1)(A) is amended to read: (d)(1)(a) A health insurance plan that does not otherwise provide for management of care under the plan, or that does not provide for the same degree of management of care for all health conditions, may provide coverage for treatment of mental health conditions through a managed care organization provided that the managed care organization is in compliance with the rules adopted by the commissioner Commissioner that assure that the system for delivery of treatment for mental health conditions does not diminish or negate the purpose of this section. In reviewing rates and forms pursuant to section 4062 of this title, the commissioner Commissioner or the Green Mountain Care
No. 79 Page 19 of 93 Board established in 18 V.S.A. chapter 220, as appropriate, shall consider the compliance of the policy with the provisions of this section. Sec. 5f. 8 V.S.A. 4512(b) is amended to read: (b) Subject to the approval of the commissioner Commissioner or the Green Mountain Care Board established in 18 V.S.A. chapter 220, as appropriate, a hospital service corporation may establish, maintain, and operate a medical service plan as defined in section 4583 of this title. The commissioner Commissioner or the Board may refuse approval if the commissioner Commissioner or the Board finds that the rates submitted are excessive, inadequate, or unfairly discriminatory, fail to protect the hospital service corporation s solvency, or fail to meet the standards of affordability, promotion of quality care, and promotion of access pursuant to section 4062 of this title. The contracts of a hospital service corporation which operates a medical service plan under this subsection shall be governed by chapter 125 of this title to the extent that they provide for medical service benefits, and by this chapter to the extent that the contracts provide for hospital service benefits. Sec. 5g. 8 V.S.A. 4513(c) is amended to read: (c) In connection with a rate decision, the commissioner Green Mountain Care Board may also make reasonable supplemental orders to the corporation and may attach reasonable conditions and limitations to such orders as he the Board finds, on the basis of competent and substantial evidence, necessary to insure ensure that benefits and services are provided at minimum cost under
No. 79 Page 20 of 93 efficient and economical management of the corporation. The commissioner Commissioner and, except as otherwise provided by 18 V.S.A. 9375 and 9376, the Green Mountain Care Board, shall not set the rate of payment or reimbursement made by the corporation to any physician, hospital, or other health care provider. Sec. 5h. 8 V.S.A. 4515a is amended to read: 4515a. FORM AND RATE FILING; FILING FEES Every contract or certificate form, or amendment thereof, including the rates charged therefor by the corporation shall be filed with the commissioner Commissioner or the Green Mountain Care Board established in 18 V.S.A. chapter 220, as appropriate, for his or her the Commissioner s or the Board s approval prior to issuance or use. Prior to approval, there shall be a public comment period pursuant to section 4062 of this title. In addition, each such filing shall be accompanied by payment to the commissioner Commissioner or the Board, as appropriate, of a nonrefundable fee of $50.00 $150.00 and the plain language summary of rate increases pursuant to section 4062 of this title. Sec. 5i. 8 V.S.A. 4584(c) is amended to read: (c) In connection with a rate decision, the commissioner Green Mountain Care Board may also make reasonable supplemental orders to the corporation and may attach reasonable conditions and limitations to such orders as he or she the Board finds, on the basis of competent and substantial evidence, necessary to insure ensure that benefits and services are provided at minimum
No. 79 Page 21 of 93 cost under efficient and economical management of the corporation. The commissioner Commissioner and, except as otherwise provided by 18 V.S.A. 9375 and 9376, the Green Mountain Care Board, shall not set the rate of payment or reimbursement made by the corporation to any physician, hospital, or other health care provider. Sec. 5j. 8 V.S.A. 4587 is amended to read: 4587. FILING AND APPROVAL OF CONTRACTS A medical service corporation which has received a permit from the commissioner of financial regulation Commissioner of Financial Regulation under section 4584 of this title shall not thereafter issue a contract to a subscriber or charge a rate therefor which is different from copies of contracts and rates originally filed with such commissioner Commissioner and approved by him or her at the time of the issuance to such medical service corporation of its permit, until it has filed copies of such contracts which it proposes to issue and the rates it proposes to charge therefor and the same have been approved by such commissioner the Commissioner or the Green Mountain Care Board established in 18 V.S.A. chapter 220, as appropriate. Prior to approval, there shall be a public comment period pursuant to section 4062 of this title. Each such filing of a contract or the rate therefor shall be accompanied by payment to the commissioner Commissioner or the Board, as appropriate, of a nonrefundable fee of $50.00 $150.00. A medical service corporation shall file
No. 79 Page 22 of 93 a plain language summary of rate increases pursuant to section 4062 of this title. Sec. 5k. 8 V.S.A. 5104 is amended to read: 5104. FILING AND APPROVAL OF RATES AND FORMS; SUPPLEMENTAL ORDERS (a)(1) A health maintenance organization which has received a certificate of authority under section 5102 of this title shall file and obtain approval of all policy forms and rates as provided in sections 4062 and 4062a of this title. This requirement shall include the filing of administrative retentions for any business in which the organization acts as a third party administrator or in any other administrative processing capacity. The commissioner Commissioner or the Green Mountain Care Board, as appropriate, may request and shall receive any information that the commissioner Commissioner or the Board deems necessary to evaluate the filing. In addition to any other information requested, the commissioner Commissioner or the Board shall require the filing of information on costs for providing services to the organization s Vermont members affected by the policy form or rate, including Vermont claims experience, and administrative and overhead costs allocated to the service of Vermont members. Prior to approval, there shall be a public comment period pursuant to section 4062 of this title. A health maintenance organization shall file a summary of rate filings pursuant to section 4062 of this title.
No. 79 Page 23 of 93 (2) The commissioner Commissioner or the Board shall refuse to approve, or to seek the Green Mountain Care board s approval of, the form of evidence of coverage, filing, or rate if it contains any provision which is unjust, unfair, inequitable, misleading, or contrary to the law of the state State or plan of operation, or if the rates are excessive, inadequate or unfairly discriminatory, fail to protect the organization s solvency, or fail to meet the standards of affordability, promotion of quality care, and promotion of access pursuant to section 4062 of this title. No evidence of coverage shall be offered to any potential member unless the person making the offer has first been licensed as an insurance agent in accordance with chapter 131 of this title. (b) In connection with a rate decision, the commissioner Board may also, with the prior approval of the Green Mountain Care board established in 18 V.S.A. chapter 220, make reasonable supplemental orders and may attach reasonable conditions and limitations to such orders as the commissioner Board finds, on the basis of competent and substantial evidence, necessary to insure ensure that benefits and services are provided at reasonable cost under efficient and economical management of the organization. The commissioner Commissioner and, except as otherwise provided by 18 V.S.A. 9375 and 9376, the Green Mountain Care Board, shall not set the rate of payment or reimbursement made by the organization to any physician, hospital, or health care provider. Sec. 5l. 18 V.S.A. 9375(b) is amended to read:
No. 79 Page 24 of 93 (b) The board Board shall have the following duties: (6) Approve, modify, or disapprove requests for health insurance rates pursuant to 8 V.S.A. 4062 within 30 days of receipt of a request for approval from the commissioner of financial regulation, taking into consideration the requirements in the underlying statutes, changes in health care delivery, changes in payment methods and amounts, protecting insurer solvency, and other issues at the discretion of the board Board; Sec. 5m. 18 V.S.A. 9381 is amended to read: 9381. APPEALS (a)(1) The Green Mountain Care board Board shall adopt procedures for administrative appeals of its actions, orders, or other determinations. Such procedures shall provide for the issuance of a final order and the creation of a record sufficient to serve as the basis for judicial review pursuant to subsection (b) of this section. (2) Only decisions by the board shall be appealable under this subsection. Recommendations to the board by the commissioner of financial regulation pursuant to 8 V.S.A. 4062(a) shall not be subject to appeal. (b) Any person aggrieved by a final action, order, or other determination of the Green Mountain Care board Board may, upon exhaustion of all administrative appeals available pursuant to subsection (a) of this section,
No. 79 Page 25 of 93 appeal to the supreme court Supreme Court pursuant to the Vermont Rules of Appellate Procedure. (c) If an appeal or other petition for judicial review of a final order is not filed in connection with an order of the Green Mountain Care board Board pursuant to subsection (b) of this section, the chair Chair may file a certified copy of the final order with the clerk of a court of competent jurisdiction. The order so filed has the same effect as a judgment of the court and may be recorded, enforced, or satisfied in the same manner as a judgment of the court. (d) A decision of the Board approving, modifying, or disapproving a health insurer s proposed rate pursuant to 8 V.S.A. 4062 shall be considered a final action of the Board and may be appealed to the Supreme Court pursuant to subsection (b) of this section. Sec. 5n. 33 V.S.A. 1811(j) is amended to read: (j) The commissioner Commissioner or the Green Mountain Care Board established in 18 V.S.A. chapter 220, as appropriate, shall disapprove any rates filed by any registered carrier, whether initial or revised, for insurance policies unless the anticipated medical loss ratios for the entire period for which rates are computed are at least 80 percent, as required by the Patient Protection and Affordable Care Act (Public Law 111-148).
No. 79 Page 26 of 93 Catamount Health and VHAP Sec. 6. 8 V.S.A. 4080d is amended to read: 4080d. COORDINATION OF INSURANCE COVERAGE WITH MEDICAID Any insurer as defined in section 4100b of this title is prohibited from considering the availability or eligibility for medical assistance in this or any other state under 42 U.S.C. 1396a (Section 1902 of the Social Security Act), herein referred to as Medicaid, when considering eligibility for coverage or making payments under its plan for eligible enrollees, subscribers, policyholders, or certificate holders. This section shall not apply to Catamount Health, as established by section 4080f of this title. Sec. 7. 8 V.S.A. 4080g(b) is amended to read: (b) Small group plans. (11)(A) A registered small group carrier may require that 75 percent or less of the employees or members of a small group with more than 10 employees participate in the carrier s plan. A registered small group carrier may require that 50 percent or less of the employees or members of a small group with 10 or fewer employees or members participate in the carrier s plan. A small group carrier s rules established pursuant to this subdivision shall be applied to all small groups participating in the carrier s plans in a consistent and nondiscriminatory manner.
No. 79 Page 27 of 93 (B) For purposes of the requirements set forth in subdivision (A) of this subdivision (11), a registered small group carrier shall not include in its calculation an employee or member who is already covered by another group health benefit plan as a spouse or dependent or who is enrolled in Catamount Health, Medicaid, the Vermont health access plan, or Medicare. Employees or members of a small group who are enrolled in the employer s plan and receiving premium assistance under 33 V.S.A. chapter 19 the Health Insurance Premium Payment program established pursuant to Section 1906 of the Social Security Act, 42 U.S.C. 1396e, shall be considered to be participating in the plan for purposes of this subsection. If the small group is an association, trust, or other substantially similar group, the participation requirements shall be calculated on an employer-by-employer basis. Sec. 8. 8 V.S.A. 4088i is amended to read: 4088i. COVERAGE FOR DIAGNOSIS AND TREATMENT OF EARLY CHILDHOOD DEVELOPMENTAL DISORDERS (a)(1) A health insurance plan shall provide coverage for the evidence-based diagnosis and treatment of early childhood developmental disorders, including applied behavior analysis supervised by a nationally board-certified behavior analyst, for children, beginning at birth and continuing until the child reaches age 21.
No. 79 Page 28 of 93 (2) Coverage provided pursuant to this section by Medicaid, the Vermont health access plan, or any other public health care assistance program shall comply with all federal requirements imposed by the Centers for Medicare and Medicaid Services. (f) As used in this section: (7) Health insurance plan means Medicaid, the Vermont health access plan, and any other public health care assistance program, any individual or group health insurance policy, any hospital or medical service corporation or health maintenance organization subscriber contract, or any other health benefit plan offered, issued, or renewed for any person in this state State by a health insurer, as defined in 18 V.S.A. 9402. The term does not include benefit plans providing coverage for specific diseases or other limited benefit coverage. Sec. 9. 8 V.S.A. 4089j is amended to read: 4089j. RETAIL PHARMACIES; FILLING OF PRESCRIPTIONS (c) This section shall apply to Medicaid, the Vermont health access plan, the VScript pharmaceutical assistance program, and any other public health care assistance program.
No. 79 Page 29 of 93 Sec. 10. 8 V.S.A. 4089w is amended to read: 4089w. OFFICE OF HEALTH CARE OMBUDSMAN (h) As used in this section, health insurance plan means a policy, service contract or other health benefit plan offered or issued by a health insurer, as defined by 18 V.S.A. 9402, and includes the Vermont health access plan and beneficiaries covered by the Medicaid program unless such beneficiaries are otherwise provided ombudsman services. Sec. 11. 8 V.S.A. 4099d is amended to read: 4099d. MIDWIFERY COVERAGE; HOME BIRTHS (d) As used in this section, health insurance plan means any health insurance policy or health benefit plan offered by a health insurer, as defined in 18 V.S.A. 9402, as well as Medicaid, the Vermont health access plan, and any other public health care assistance program offered or administered by the state State or by any subdivision or instrumentality of the state State. The term shall not include policies or plans providing coverage for specific disease or other limited benefit coverage. Sec. 12. 8 V.S.A. 4100b is amended to read: 4100b. COVERAGE OF CHILDREN (a) As used in this subchapter:
No. 79 Page 30 of 93 (1) Health plan shall include, but not be limited to, a group health plan as defined under Section 607(1) of the Employee Retirement Income Security Act of 1974, and a nongroup plan as defined in section 4080b of this title, and a Catamount Health plan as defined in section 4080f of this title. Sec. 13. 8 V.S.A. 4100e is amended to read: 4100e. REQUIRED COVERAGE FOR OFF-LABEL USE (b) As used in this section, the following terms have the following meanings: (1) Health insurance plan means a health benefit plan offered, administered, or issued by a health insurer doing business in Vermont. (2) Health insurer is defined by section 18 V.S.A. 9402 of Title 18. As used in this subchapter, the term includes the state State of Vermont and any agent or instrumentality of the state State that offers, administers, or provides financial support to state government, including Medicaid, the Vermont health access plan, the VScript pharmaceutical assistance program, or any other public health care assistance program. Sec. 14. 8 V.S.A. 4100j is amended to read: 4100j. COVERAGE FOR TOBACCO CESSATION PROGRAMS
No. 79 Page 31 of 93 (b) As used in this subchapter: (1) Health insurance plan means any health insurance policy or health benefit plan offered by a health insurer, as defined in 18 V.S.A. 9402, as well as Medicaid, the Vermont health access plan, and any other public health care assistance program offered or administered by the state State or by any subdivision or instrumentality of the state State. The term does not include policies or plans providing coverage for specified disease or other limited benefit coverage. Sec. 15. 8 V.S.A. 4100k is amended to read: 4100k. COVERAGE FOR TELEMEDICINE SERVICES (g) As used in this subchapter: (1) Health insurance plan means any health insurance policy or health benefit plan offered by a health insurer, as defined in 18 V.S.A. 9402, as well as Medicaid, the Vermont health access plan, and any other public health care assistance program offered or administered by the state State or by any subdivision or instrumentality of the state State. The term does not include policies or plans providing coverage for specified disease or other limited benefit coverage.
No. 79 Page 32 of 93 Sec. 16. 13 V.S.A. 5574(b) is amended to read: (b) A claimant awarded judgment in an action under this subchapter shall be entitled to damages in an amount to be determined by the trier of fact for each year the claimant was incarcerated, provided that the amount of damages shall not be less than $30,000.00 nor greater than $60,000.00 for each year the claimant was incarcerated, adjusted proportionally for partial years served. The damage award may also include: (1) Economic damages, including lost wages and costs incurred by the claimant for his or her criminal defense and for efforts to prove his or her innocence. (2) Notwithstanding the income eligibility requirements of the Vermont Health Access Plan in section 1973 of Title 33, and notwithstanding the requirement that the individual be uninsured, up Up to 10 years of eligibility for the Vermont Health Access Plan using state-only funds state-funded health coverage equivalent to Medicaid services. Sec. 17. 18 V.S.A. 1130 is amended to read: 1130. IMMUNIZATION PILOT PROGRAM (a) As used in this section: (5) State health care programs shall include Medicaid, the Vermont health access plan, Dr. Dynasaur, and any other health care program providing
No. 79 Page 33 of 93 immunizations with funds through the Global Commitment for Health waiver approved by the Centers for Medicare and Medicaid Services under Section 1115 of the Social Security Act. Sec. 18. 18 V.S.A. 3801 is amended to read: 3801. DEFINITIONS As used in this subchapter: (1)(A) Health insurer shall have the same meaning as in section 9402 of this title and shall include: (i) a health insurance company, a nonprofit hospital and medical service corporation, and health maintenance organizations; (ii) an employer, a labor union, or another group of persons organized in Vermont that provides a health plan to beneficiaries who are employed or reside in Vermont; and (iii) except as otherwise provided in section 3805 of this title, the state State of Vermont and any agent or instrumentality of the state State that offers, administers, or provides financial support to state government. (B) The term health insurer shall not include Medicaid, the Vermont health access plan, Vermont Rx, or any other Vermont public health care assistance program.
No. 79 Page 34 of 93 Sec. 19. 18 V.S.A. 4474c(b) is amended to read: (b) This chapter shall not be construed to require that coverage or reimbursement for the use of marijuana for symptom relief be provided by: (1) a health insurer as defined by section 9402 of this title, or any insurance company regulated under Title 8; (2) Medicaid, Vermont health access plan, and or any other public health care assistance program; (3) an employer; or (4) for purposes of workers compensation, an employer as defined in 21 V.S.A. 601(3). Sec. 20. 18 V.S.A. 9373 is amended to read: 9373. DEFINITIONS As used in this chapter: (8) Health insurer means any health insurance company, nonprofit hospital and medical service corporation, managed care organization, and, to the extent permitted under federal law, any administrator of a health benefit plan offered by a public or a private entity. The term does not include Medicaid, the Vermont health access plan, or any other state health care assistance program financed in whole or in part through a federal program.
No. 79 Page 35 of 93 Sec. 21. 18 V.S.A. 9471 is amended to read: 9471. DEFINITIONS As used in this subchapter: (2) Health insurer is defined by section 9402 of this title and shall include: (A) a health insurance company, a nonprofit hospital and medical service corporation, and health maintenance organizations; (B) an employer, labor union, or other group of persons organized in Vermont that provides a health plan to beneficiaries who are employed or reside in Vermont; (C) the state State of Vermont and any agent or instrumentality of the state State that offers, administers, or provides financial support to state government; and (D) Medicaid, the Vermont health access plan, Vermont Rx, and any other public health care assistance program. Sec. 22. 33 V.S.A. 1807(b) is amended to read: (b) Navigators shall have the following duties:
No. 79 Page 36 of 93 (3) Facilitate facilitate enrollment in qualified health benefit plans, Medicaid, Dr. Dynasaur, VPharm, VermontRx, and other public health benefit programs; (5) Provide provide information in a manner that is culturally and linguistically appropriate to the needs of the population being served by the Vermont health benefit exchange; and (6) Distribute distribute information to health care professionals, community organizations, and others to facilitate the enrollment of individuals who are eligible for Medicaid, Dr. Dynasaur, VPharm, VermontRx, other public health benefit programs, or the Vermont health benefit exchange in order to ensure that all eligible individuals are enrolled.; and (7) Provide provide information about and facilitate employers establishment of cafeteria or premium-only plans under Section 125 of the Internal Revenue Code that allow employees to pay for health insurance premiums with pretax dollars. Sec. 23. 33 V.S.A. 1901(b) is amended to read: (b) The secretary may charge a monthly premium, in amounts set by the general assembly, to each individual 18 years or older who is eligible for enrollment in the health access program, as authorized by section 1973 of this title and as implemented by rules. All premiums collected by the agency of human services or designee for enrollment in the health access program shall
No. 79 Page 37 of 93 be deposited in the state health care resources fund established in section 1901d of this title. Any co-payments, coinsurance, or other cost sharing to be charged shall also be authorized and set by the general assembly. [Deleted.] Sec. 24. 33 V.S.A. 1903a is amended to read: 1903a. CARE MANAGEMENT PROGRAM (a) The commissioner Commissioner of Vermont health access Health Access shall coordinate with the director Director of the Blueprint for Health to provide chronic care management through the Blueprint and, as appropriate, create an additional level of care coordination for individuals with one or more chronic conditions who are enrolled in Medicaid, the Vermont health access plan (VHAP), or Dr. Dynasaur. The program shall not include individuals who are in an institute for mental disease as defined in 42 C.F.R. 435.1009. Sec. 25. 33 V.S.A. 1997 is amended to read: 1997. DEFINITIONS As used in this subchapter: (7) State public assistance program, includes, but is not limited to, the Medicaid program, the Vermont health access plan, VPharm, VermontRx, the state children s health insurance program State Children s Health Insurance Program, the state State of Vermont AIDS medication assistance program Medication Assistance Program, the General Assistance program, the
No. 79 Page 38 of 93 pharmacy discount plan program Pharmacy Discount Plan Program, and the out-of-state counterparts to such programs. Sec. 26. 33 V.S.A. 1998(c)(1) is amended to read: (c)(1) The commissioner Commissioner may implement the pharmacy best practices and cost control program Pharmacy Best Practices and Cost Control Program for any other health benefit plan within or outside this state State that agrees to participate in the program. For entities in Vermont, the commissioner Commissioner shall directly or by contract implement the program through a joint pharmaceuticals purchasing consortium. The joint pharmaceuticals purchasing consortium shall be offered on a voluntary basis no later than January 1, 2008, with mandatory participation by state or publicly funded, administered, or subsidized purchasers to the extent practicable and consistent with the purposes of this chapter, by January 1, 2010. If necessary, the department of Vermont health access Department of Vermont Health Access shall seek authorization from the Centers for Medicare and Medicaid to include purchases funded by Medicaid. State or publicly funded purchasers shall include the department of corrections Department of Corrections, the department of mental health Department of Mental Health, Medicaid, the Vermont Health Access Program (VHAP), Dr. Dynasaur, VermontRx, VPharm, Healthy Vermonters, workers compensation, and any other state or publicly funded purchaser of prescription drugs.